Physician Assistant Exam: The Testes and Surrounding Areas
A lot of health conditions can affect the testes and these will be covered on the Physician Assistant Exam. Not only are the conditions important clinically, but they’re also high-yield for tests. From torsion to cancer to infection, be aware of these conditions.
Testicular torsion is a condition you wouldn’t wish on your worst enemy. Here, the testis is literally twisted around the spermatic cord, cutting off the blood supply. Testicular torsion usually occurs in young males. Risk factors include cryptorchidism, which is also a risk factor for testicular cancer.
A typical presentation involves sudden onset acute unilateral testicular pain and scrotal swelling. You can use a Doppler ultrasound to evaluate for torsion. Testicular torsion is a surgical emergency because the blood supply is compromised.
Testicular conditions ending in -cele
You should be aware of three terms ending in cele that affect the testes: hydrocele, varicocele, and spermatocele. Cele comes from the Greek word meaning “tumor.”
Varicocele: A varicocele is simply a varicosity within the spermatic vein. The most common presentation is a left-sided nontender mass. A classic description is that of a “bag of worms.” It increases in size with positive intra-abdominal pressure and reduces in size with lying down or scrotal elevation. Ultrasound is the diagnostic test of choice, and surgical intervention can be curative if the patient feels pain or is infertile.
Spermatocele: A spermatocele is just that: a mass that contains sperm. Spermatoceles are small and can be diagnosed by ultrasound. The usual treatment is just observation.
Hydrocele: A hydrocele is a soft fluid-filled mass that contains the remnants of the tunica vaginalis. A hernia may also be present. The treatment can be observation or surgical intervention.
Hydroceles and spermatoceles transilluminate, whereas varicoceles do not. You may see this point in a test question as a clinical clue to diagnosing these conditions.
Priapism is basically an erection that’s maintained for several hours, usually greater than 4 hours. This is a medical emergency, and it’s not associated with sexual stimulation.
In any African-American patient presenting with priapism, do a hemoglobin electrophoresis to evaluate for sickle-cell disease, which can be a cause. Hematologic malignancies like leukemia and clotting disorders can cause priapism as well. Medications associated with priapism include antihypertensives, antipsychotics, antidepressants, PDE5 inhibitors, and anticoagulants.
You direct treatment at the underlying cause. In many cases, this requires an emergency urologic referral, because priapism is a urologic emergency for decompression of the corpus cavernosa. In cases of sickle-cell disease, the patient needs IV hydration, oxygen, administration of a beta-2 agonist to the affected area, and exchange transfusions.
Erectile dysfunction (ED)
In erectile dysfunction, the affected person is unable to maintain a sufficient erection in the face of sexual stimulation. This failure to perform can be psychological in origin, although a medical evaluation should be done, especially in a middle-aged or older man.
Common medical conditions can predispose someone to erectile dysfunction, including hypertension (because the side effect profile of many classes of antihypertensive medications includes erectile dysfunction), diabetes, hypothyroidism, low testosterone levels, high cholesterol, peripheral vascular disease, and tobacco and/or excessive alcohol use. Other causes include prior trauma, either to the affected area or any type of spinal injury or surgery that could have affected nerve supply to the area.
Sildenafil (Viagra) is a vasodilator used in the management of erectile dysfunction. The medication increases blood supply to the area. It can lower blood pressure, especially if it’s given with nitroglycerin. In addition to sildenafil, other treatments for erectile dysfunction include treating the underlying medical condition. Counseling is recommended, especially for men in whom the cause may be less physiological and more psychological.
Infection: The -itises
Common infections that affect the testicle and surrounding anatomy include orchitis, epididymitis, and urethritis:
Orchitis: Orchitis refers to an infection of the testicular area, and the cause is commonly bacterial. The affected person presents with fever, pain, and swelling. An ultrasound can be diagnostic, and the urinalysis can show signs of an infection. The empiric antibiotic therapy for orchitis is similar to that of epididymitis (see the next bullet). Scrotal elevation is also recommended.
Epididymitis: Epididymitis is an infection of the epididymis. Infection spreads via the vas deferens. The onset is sudden, and the epididymis is swollen and tender to touch. The urinalysis can show positive pyuria.
The treatment is specific, depending on the age of the person. If he’s younger than 35, he gets ceftriaxone (Rocephin) and doxycycline for 10 days, because the etiology is epidemiologically more likely to be an STI, either gonorrhea or chlamydia. If he’s older than 35, he receives ciprofloxacin (Cipro) for 10 days.
Urethritis: Urethritis is the inflammation of the urethra. Pain with urination and urethral discharge are common presenting signs and symptoms. Urethritis is primarily associated with STIs in a male who is sexually active. The diagnosis of urethritis is made by obtaining a urethral culture (the dreaded swab). A urinalysis with culture and wet prep can also be obtained.
The treatment of urethritis is primarily antibiotic treatment. This includes ceftriaxone (Rocephin) and doxycycline (Doryx). Remember the importance of treating the partner as well, if possible.
The triad of Reiter’s syndrome (reactive arthritis) includes arthritis, conjunctivitis, and urethritis. Balanitis (infection of the glans penis) may be present as well.
Tumors of the testicle commonly occur in younger age groups. The majority of tumors are germ cell tumors, the most common being a seminoma. You don’t use the tumor markers β-hCG and alpha-fetoprotein to diagnose them. A significant risk factor for the development of a seminoma is cryptorchidism. Although patients with seminonas present with testicular enlargement, some present no symptoms. Physical examination can determine the presence of a testicular mass.
After diagnosing testicular cancer, staging is done, including a CT scan of the abdomen/pelvis with contrast. Treatment depends on the type of cancer. Seminomas are very responsive to radiation. Surgical intervention depends on the extent of tumor spread.